Retained Catheter Fragment from a FracturedTunneled Catheter—A Rare and Potentially LethalComplication

Anand Reddy,* Anondo Stangl,† and Brian Radbill‡

*Department of Nephrology, Mount Sinai School of Medicine, New York, †Department of Radiology, MountSinai School of Medicine, New York City, New York, and ‡Department of Nephrology, Mount Sinai School ofMedicine, New York City, New York

ABSTRACT

Despite efforts to curtail central vein catheter use for dialysiscatheters are frequently used in the treatment of end-stage renaldisease (ESRD). In 2006, 82% of patients in the USA initiateddialysis via a catheter. The overall of tunnelled cuffed catheter(TCC)usewas 35%greater in 2005 comparedwith 1996.Dialy-

sis catheter tip fracture is a rare and potentially serious compli-cation. Herein, we present the case of an incidental finding of aretained catheter fragment from a fractured TCC in the rightatrium. Fragment retrieval (via snare technique) and subse-quent placement of anewcentral venous catheter are outlined.

Well-functioning, long-term vascular access remainsthe Achilles’ heel of hemodialysis (HD) and is essentialto providing efficient dialysis therapy. Vascular access isa major cause of morbidity and mortality (1) in end-stage renal disease (ESRD), accounting for the majorityof hospitalizations (2) and 14% of all ESRD expenses(an estimated $1 billion annually) (1). There are threemain types of longterm vascular access: native arteriove-nous fistula (AVF), arteriovenous graft (AVG) and cen-tral vein catheter (CVC), typically a tunnelled cuffedcatheter (TCC). Originally hailed as a viable alternativeto the arteriovenous graft (AVG), TCCs have been asso-ciated with as much as a threefold increased mortalityrate as compared to AVFs (3,4). Sepsis-related death is100 times greater in dialysis patients than in the generalpopulation, with infection-related death and all-causemortality highest in those with TCCs (5). Approximately20% of patients dialyzed through a TCC develop osteo-myelitis, septic arthritis, and endocarditis and often die,regardless of whether or not the infected catheter isremoved (6,7). In addition to infection-related complica-tions, a several-fold increase in cardiovascular risk hasalso been associated with catheter use (5). The cost ofplacing a TCC is approximately $13,000, and that of

treating one TCC-related episode of bacteremia is ashigh as $45,000 (5).

Case Report

A 35-year-old caucasian woman presented with ahistory of ESRD on HD via a right internal jugularvein CVC. Other past medical history included a 22-yearhistory of insulin-dependent diabetes mellitus (IDDM)complicated by gastroparesis, peripheral vascular dis-ease, ischemic cardiomyopathy status-post AICD and avocal cord lesion requiring a prior tracheostomy. Patientpresented to the emergency department because ofshortness of breath attributed to difficulty managing hertracheostomy. Her initial physical examination andbloodworkwere unremarkable except for elevated bloodurea nitrogen and creatinine and a potassium of5.6 mEq ⁄ l. Routine chest X-ray revealed mild pulmo-nary congestion, right internal jugular CVC, and whatappeared to be a catheter fragment in the cardiac silhou-ette (Fig. 1A and B). CT scan confirmed the presence ofa foreign body (Fig. 1C), most likely a fractured cathetertip, in the right atrium. After discussion with the patientand the interventional radiology team regarding poten-tial risks and benefits of catheter tip retrieval, the cathe-ter fragment was successfully removed by percutaneoussnare technique under fluoroscopy guidance through afemoral approach (Fig. 2A–E). The catheter tip frag-ment and the indwelling CVC, which was exchanged atthe time of the procedure, were sent for pathology. Itwas later revealed that the fragment was part of a

Address correspondence to: Anand Reddy, One GustaveL.Levy Place, Mount Sinai School of Medicine, New York, NY10029, Tel.: +1-212-241-8002, Fax: +1-212-987-0389, or e-mail:anand.reddy@mssm.edu.

Seminars in Dialysis—Vol 23, No 5 (September–October)2010 pp. 536–539DOI: 10.1111/j.1525-139X.2010.00756.xª 2010 Wiley Periodicals, Inc.

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different catheter than the indwelling CVC (Fig. 3),which was found to be intact.

Discussion

Here we described a case of a retained catheter frag-ment incidentally discovered in the right atrium of anESRDpatient with a history ofmultiple prior CVCs suc-cessfully removed percutaneously via a snare technique.In addition to pulmonary embolization (8–10), otherpotential serious complications of dialysis catheter tipfracture may include: myocardial rupture, valvular per-foration, pulmonary artery rupture, infective endocardi-tis, and pulmonary abscess.

The fractured catheter component may lodge any-where distal to its original location including the venacava, right atrium, right ventricle, and pulmonary artery,depending on the size and weight of the broken segment(11). Removal of the foreign body by a nonsurgical per-cutaneous approach is possible in most cases. This canbe done using snares, hooked guide wires, Fogarty bal-loon catheters, orDormia baskets (12).

Central venous catheter fracture has primarily beenreported in patients with central venous access devicesused primarily for the administration of chemotherapy.These catheters are commonly inserted in the subclavian

vein and fracture is attributed to chronic mechanicalfriction and shear forces on the catheter as it passesbetween the clavicle and the first rib (4,13). The ‘‘pinch-off’’ sign, characterized by a kink or narrowing of thecatheter at this position, is an early warning sign forimpending catheter fracture at that site (4). This type ofmechanical friction and catheter stenosis may beavoided by choosing an internal jugular vein approach,which is better, suited for cuffed tunneled hemodialysiscatheters but not for long term implanted chemotherapydevices (10).

Early indications of catheter fracture are not welldescribed. In a few case reports, associated symptoms ⁄findings included intermittent catheter malfunction,resistance to fluid administration, pain during dialysistreatment, chest pain and palpitations, all of which arerelatively nonspecific (10,14,15). The majority of casereports are asymptomatic. Our patient did present withshortness of breath but this was directly attributable todifficulties with her tracheostomy. During a recent hos-pital admission, the patient developed an episode of ven-tricular tachycardia; however, given the patient’s historyof reduced LV function and prior dysrhythmia requiringAICD placement, we do not feel this was related to thepresence of the retained catheter fragment.

In our patient it was not clear why the catheter frac-tured but most likely as various reports have shown that

A

C

B

Fig. 1. Imaging studies (A) CXR lateral view; (B) CXR PA; (C) CT scan.

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vascular catheter could be affixed to the wall of the supe-rior vena cava or the atrium (16–21). Tradional methodsof catheter removal not only cause vascular or atrialavulsion but may also result in catheter breakage withresultant retention of the broken fragments (16,17).Recently a novel new Laser sheath technique wasapplied to remove the retained catheters which showncatheter withdrawal without any risk of catheter fracture(22).Unfortunately, as we have learned all too well, the

dialysis access catheter is a double-edged sword. Withthe frequent use of cuffed catheters it is important to be

aware of all potential problems (however rare) and rec-ognize the need for amultidisciplinary approach inman-aging vascular access complications and failure.

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A B

D C

Fig. 2. (A–D) Percutaneous transvenous snare technique of intracardiac catheter fragment retrieval removal approach.

Fig. 3. Catheter fragment and catheter after removal.

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